KAMANA TYLER

CLINICAL DENIALS MANAGEMENT, III

CONTACT

469-***-****

ad2d07@r.postjobfree.com

CAREER SUMMARY

To obtain a challenging position in a company that will allow me to broaden my experiences & skills. I have excellent Interpersonal & communication skills, ability to work in a team setting, work well under pressure, multi-tasked, highly motivated & quick learner.

SKILLS

Shorthand Transcription

Dictaphone, 10 key by touch

ICD-9 & CPT,

Payer reimbursement

Trending

Novitas, Ecare,

Claim logic, CodeRyte, Availity, NPPES, Waystar, Xactimed, MS Word, ACE,

Inovalon, PNC, Performant, Livanta, VI Web, Cotivit, Faxcom, PNC, ONBASE

Process improvement

Cerner Systems

Citrix Medical Systems

Meditech Medical Systems

EPIC

EXPERIENCE

Denials Specialist Auditor

Frisco, Texas

Conifer Health Solutions

2023-present

•Validating dispute reasons following Explanation of Benefits (EOB) review

•Ensures coding in DCM is accurate and reflects the denial reasons

•Coordinate with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary

•Generate an appeal based on the dispute reason and contract terms specific to the payor

•Escalate exhausted appeal efforts for resolution

• Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for Internet enabled Managed Care System (IMaCS) adjudication issues, and referral to refund unit on overpayments

• Perform research and makes determination of corrective actions and takes appropriate steps to code the DCM system and route account appropriately

•Escalate denial or payment variance trends to NIC leadership team for payor escalation

Clinical Denial Management, III

Dallas, Texas

UT Southwestern Medical Center

2012- 2023

CONTACTS PAYERS, VIA WEBSITE, PHONE AND/OR CORRESPONDENCE, REGARDING REIMBURSEMENT OF UNPAID ACCOUNTS OVER THIRTY (30) DAYS OR MORE.

INTERPRETS MANAGED CARE CONTRACTS AND/OR MEDICARE AND MEDICAID RULES AND REGULATIONS TO ENSURE PROPER REIMBURSEMENT/COLLECTION.

IDENTIFIES DENIAL TRENDS AND RESEARCHES TO RESOLVE THE TRENDING ISSUES.

FUNCTIONS AS RESOURCE PERSON FOR DEPARTMENTAL PERSONNEL TO ANSWER QUESTIONS AND ASSISTS WITH PROBLEM RESOLUTION

FUNCTIONS AS LIAISON BETWEEN CLINICAL DEPARTMENTS AND THIRD PARTY PAYERS

VERIFIES DATA INTEGRITY AND ACCURACY.

ENTERS DETAILS SUCH AS PAYMENTS, ACCOUNT INFORMATION AND CALL LOGS INTO THE COMPUTER SYSTEM.

RESPONDS TO DEPARTMENT REQUESTS VIA EMAIL REGARDING DENIALS AND QUESTIONS ON ACCOUNTS.

KNOWLEDGE OF ICD-10, CPT, MANAGED CARE GUIDELINES, CMS RULES AND REGULATIONS

INTERPRET E&M NOTES AND MEDICAL RECORDS

REVIEW, RESEARCH & RESOLVE CODING DENIAL S FOR COMPLEX,

DIAGNOSTIC STUDIES, INTERVENTIONAL CARDIOLOGY, PM&R,

INTERNAL MEDICINE, RADIOLOGY, TRANSPLANT (HEART, KIDNEY & LUNGS)

Clinical Denial Management, II

Dallas, Texas

UT Southwestern Medical Center

2012-present

VALIDATED DENIAL REASONS AND, IF NECESSARY, GENERATES APPEAL BASED ON DISPUTE REASON AND CONTRACT TERMS.

REVIEWED AUTHORIZATION DENIALS AND DETERMINES WHETHER APPEAL REQUIRES A CLINICAL REVIEW OR CAN BE HANDLED FROM A TECHNICAL PERSPECTIVE.

RESEARCHED CONTRACT TERMS/INTERPRETATION AND COMPILES NECESSARY SUPPORTING DOCUMENTATION FOR APPEALS, TERMS & CONDITIONS FOR INTERNET BASED CONTRACT SYSTEM.

PERFORMED RESEARCH AND CORRECTIVE ACTIONS FOR THE FOLLOWING: INCORRECT PATIENT TYPE, FACILITY AUDIT, INCORRECT ADJUST ADJUDICATION, NON-COVERED SERVICES, REQUESTS NURSE AUDITS, UPDATES PAYER CODE.

EXTENSIVE KNOWLEDGE OF MANAGED MEDICAID AND MANAGED MEDICARE PAYERS.

CREATED AND DISTRIBUTED JOB AIDS WITH CURRENT PAYER INFORMATION AND UPDATES.

Workers Compensation Billing Analyst

Addison, Texas

2011-2012

RESPONSIBLE FOR THE DAY-TO-DAY ACCURATE PROCESSING AND REVIEW OF MEDICAL BILLS VALIDATED PAYER REIMBURSEMENT GUIDELINES

ADJUSTED CLAIMS ACCORDING TO CONTRACTED PPO DISCOUNTS

IDENTIFIES ROOT CAUSE, DETERMINES CORRECTIVE ACTION, AND RESOLVES RELATED ISSUES TO RELEASE CLAIM FOR BILLING

MAKES CALLS TO INSURANCES, PATIENTS, OR INTERNAL PERSONNEL FOR INFORMATION REQUESTS TO DETERMINE APPROPRIATE CORRESPONDENCE TO SEND

BILLED PRIMARY AND SECONDARY INSURANCES

RESPOND TO INFORMATION REQUESTS TO ENSURE INFORMATION PROVIDED IS APPROPRIATE AND COMPLETE

CORRECTED CPT CODING ERRORS.

EDUCATION

CPC-AAPC

Everest College

Contact this candidate